Developmental services in primary care for low-income children: Clinicians’ perceptions of the healthy steps for young children program

Difficulties with providing quality primary health care for low-income Americans have been well documented. Few studies have addressed the challenges faced by pediatric clinicians serving low-income families or whether practice-based interventions improve clinicians’ ability to provide quality preventive health services. We investigated if, over time, the Healthy Steps for Young Children program affected the practices and perceptions of clinicians in pediatric primary care practices serving low-income families compared to practices serving more affluent families. Self-administered questionnaires were completed at baseline (N=104) and at 30 months (N=91) by clinicians at 20 pediatric practices participating in the Healthy Steps program. Practices were divided into three groups: those serving families with low, middle, and high incomes. Barriers to providing care, provision of preventive developmental services, and perceptions of care were assessed at baseline and at 30 months after introducing the program. Across all income groups and over time, clinicians were more likely to report the provision of preventive developmental health services. Clinicians in low-income practices reported increased problems with both reimbursement and time barriers; clinicians in high-income practices reported increased problems with reim-bursement. At 30 months, clinicians serving low-income families reported the greatest positive changes in their perceptions about the quality of care provided by their practices. They also were more likely to strongly agree that they gave support to families and to be very satisfied with the ability of their clinical staff to meet the developmental needs of children. We found that Healthy Steps was successful in universally increasing developmental services despite the reported practice barriers for both low- and high-income practices. The Healthy Steps program enabled low-income practices to achieve similar levels of clinician satisfaction as middle- and high-income practices despite having reported lower levels at the beginning months of the program. The Healthy Steps for Young Children Program is a program of the Commonwealth Fund, local funders, and health care providers across the nation. It is cosponsored by the American Academy of Pediatrics. Funding for the Healthy Steps National Evaluation is being provided by the Commonwealth Fund, the Robert Wood Johnson Foundation, the Atlantic Philanthropic Foundation, and local funders. The views presented here are those of the authors and not necessarily those of the funders, their directors, officers, or staff.     

Children of working low-income families in California: does parental work benefit children's insurance status,access, and utilization of primary health care?

OBJECTIVE: To examine financial and nonfinancial access to care and utilization of primary health care services among children of working low-income families earning below 200 percent of the federal poverty level in California, and to compare them to children in nonworking low-income families and in families earning over 200 percent of poverty. DATA SOURCES/STUDY SETTING: The 1994 National Health Interview survey weighted to reflect population estimates for California. STUDY DESIGN: This cross-sectional study of 3,831 children under age 19 focuses on financial access, that is, the prevalence and continuity of health insurance coverage; structural access, including the presence of a usual source of care, the predominant care source, its responsiveness to patient's needs, and any indications of delayed or missed care; and utilization of health care measured by the presence of an outpatient doctor's visit and the mean number of visits relative to child health status. DATA COLLECTION: The study uses secondary analysis. FINDINGS: Compared to children of nonworking low-income parents and to nonpoor children, children of working low-income parents were more likely to be uninsured (32.1 percent versus 15.6 percent and 10.3 percent, p = .0001) and to experience disruptions in insurance coverage (p = .0009). These differences persisted after controlling for other covariates in multivariate analyses. Children of working low-income parents did not differ significantly from children of nonworking low-income parents on measures of structural access or utilization, after adjusting for other covariates. However, they differed significantly from nonpoor children on structural access and utilization, and these differences mostly persisted after adjusting for other covariates (odds ratios from 1.5 to 2.9). Similar patterns were observed when children of full-time, year-round working parents with low earnings were compared with the two reference populations. CONCLUSION: Children in working low-income families in California have some of the worst access problems. Even full attachment to the workforce does not guarantee health insurance benefits, access to care, or improved health care use for children of low-income parents. These children are not better off than other low-income children of nonworking parents and are much worse off than nonpoor children. Expansion of health insurance coverage through Healthy Families and Medi-Cal, and attention to nonfinancial barriers to care for working low-income families may help to reduce these disparities.     

Equity of primary care service delivery for low income “sicker” adults across 10 OECD countries

Background

Despite significant investments to support primary care internationally, income-based inequities in access to quality health care are present in many high-income countries. This study aims to determine whether low- and middle-income groups are more likely to report poor quality of primary care (PC) than high-income groups cross-nationally.

Methods

The 2011 Commonwealth Fund Telephone Survey of Sicker Adults is a cross-sectional study across eleven countries. Respondents were recruited from randomly selected households. We used data from surveys conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. We identified all questions relating to primary care performance, and categorized these into five dimensions: 1) access to care, 2) coordination 3) patient-centered care, and 4) technical quality of care. We used logistic regression with low and middle-income as the comparison groups and high-income as the referent.

Results

Fourteen thousand two hundred sixty-two respondents provided income data. Countries varied considerably in their extent of income disparity. Overall, 24.7% were categorized as low- and 13.9% as high-income. The odds of reporting poor access to care were higher for low- and middle-income than high-income respondents in Canada, New Zealand and the US. Similar results were found for Sweden and Norway on coordination; the opposite trend favoring the low- and middle-income groups was found in New Zealand, United Kingdom, and the United States. The odds of reporting poor patient-centered care were higher for low-income than high-income respondents in the Netherlands, Norway, and the US; in Australia, this was true for low- and middle-income respondents. On technical quality of care, the odds of reporting poor care were higher for the low- and middle-income comparisons in Canada and Norway; in Germany, the odds were higher for low-income respondents only. The odds of reporting poor technical quality of care were higher for high-income than low-income respondents in the Netherlands.

Conclusion

Inequities in quality PC for low and middle income groups exist on at least one dimension in all countries, including some that in theory provide universal access. More research is needed to fully understand equity in the PC sector.

     

Quality of stroke guidelines in low- and middle-income countries: a systematic review

ObjectiveTo identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries.MethodsWe systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences.FindingsWe reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations.ConclusionGuidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.     

Expanding developmental and behavioral services for newborns in primary care: program design, delivery, and evaluation framework

BACKGROUND: Healthy Steps (HS) for Young Children strengthens the healthcare system as a source of developmental and behavioral support for parents. This series of papers presents a study of HS as implemented within a large health maintenance organization that tested the benefit of beginning intervention services during pregnancy with an extension program called "PrePare" (PP). METHODS: The design was a quasi-experimental comparison of intervention families with families receiving usual care. Within the intervention, families were assigned randomly to begin receiving Healthy Steps services prenatally (PP+HS) or shortly after birth (HS). We used a systems model, PRECEDE/PROCEED, for planning, implementation, and process evaluation. Outcomes examined when the infants were aged 3 months included changes in family social support and capacity for parenting, parenting behaviors, and satisfaction and loyalty to the health plan. RESULTS: The sample of 439 families was distributed as follows: usual care (n=136), prenatal initiation of services (PP+HS; n=151), and postnatal Healthy Steps (HS; n=152). Information about program implementation, including provider satisfaction, is provided for the early phases of the study (through age 3 months). The intervention was delivered with fidelity and with minimal disruption to the practice styles of pregnancy providers, most of whom considered the program valuable to their patients. Relative to families in the comparison group, families in the intervention group received more usual care services and more intervention-specific services. CONCLUSIONS: The pregnancy and newborn phases of the intervention were embedded successfully within the existing healthcare delivery system. The program was considered valuable for parents by providers and parents. Participating families received more services and a greater variety of services than families in usual care. Whether these differences result in beneficial outcomes for families or the health plan are topics of the subsequent papers.     

PrePare: a program of enhanced prenatal services within health-maintenance organization settings

This paper presents the conceptual framework and implementation strategies of a relationship-focused behavioral intervention for pregnant women and their families. The program, PrePare ('Prenatal Parenting'), was designed as a prenatal precursor to the pediatric health care model, Healthy Steps. PrePare includes preventive intervention elements that address parents' universal concerns about pregnancy and parenthood, as well as specific activities to support optimum pregnancy health and reduce high-risk behaviors. As described here, the program is embedded within a large not-for-profit health-maintenance organization (HMO). Delivery of the prenatal component is carried out by Healthy Steps interventionists through three home visits and telephone follow-up during mothers' second and third trimesters of pregnancy. An evaluation of program outcomes is underway. The design compares three groups of families, those who receive PrePare followed by Healthy Steps, Healthy Steps alone and a usual HMO-practice comparison. It is hypothesized that initiating expanded services during the prenatal period will lead to increases in reported patient satisfaction, provider satisfaction and organizational efficiency within the health care delivery system.     

Child developmental and special education service receipt: The intersection of health and poverty

BackgroundChildren born of low birth weight (LBW) and/or premature may have developmental delays and difficulties. The vulnerability, without early intervention, would have detrimental lifelong effects.ObjectivesThis study examined 1) the relationship between LBW and prematurity and the occurrence and timing of children's receipt of developmental and special education services; and 2) whether poverty intersects with LBW and prematurity affecting service receipt.MethodsThis population-based study used cross-sectional data from the National Survey of Children's Health which consisted of approximately 52,000 participants aged 1–17 between 2017 and 2018 in the United States. We conducted logistic regression to analyze the predictive relationship of LBW/prematurity and the occurrence of receiving developmental and special education services. We then conducted ordered logistic regression to examine whether LBW and prematurity predicted the timing of receiving developmental and special education services. Further, we conducted moderating analyses to examine whether the predictive relationships above varied with poverty. The analyses listed above were weighted to reflect the population drawn.ResultsChildren born with LBW and prematurity were more likely to receive developmental and special education services and they tended to receive services earlier than those born at normal weight and term. Educational disparities were evident among children in low-income families. Children of LBW in low-income families were less likely to receive earlier services than those in affluent families.ConclusionsThis study indicates developmental and special education needs of children born LBW and/or premature. With restrained assets, low-income families may need more assistance to promote optimal development for their children.     

Nutritional profile of selected expectant mothers and the cost of pregnancy

The nutritional profile during pregnancy, pregnancy-related expenditures, and pregnancy wastage were analyzed in 316 women attending a maternity or general hospital in Coimbatore, India. The sample included 195 low-income women (under Rs 600/month), 76 middle-income women (Rs 601-1500/month), and 45 high-income women (above Rs 1500/month). 51% of study participants had 3 fewer children; 71% were literate. The pregnancy diet of low-income women was starchy and inadequate in terms of all nutrients except vitamin C. Middle- and high-income women reported a satisfactory intake of all essential nutrients. The mean weight gain during pregnancy for low-, middle-, and high-income women was 6.41 kg, 7.37 kg, and 8.33 kg, respectively, while the mean hemoglobin level was 10.52, 10.74, and 10.96 gm/100 ml, respectively. No study participant was found to be anemic. The rate of pregnancy wastage was 11.8% among low-income women, 7.9% in the middle-income group, and 4.4% among high-income women; mean birthweight was 2.9 kg for low-income mothers and 3.1 kg for the offspring of both middle- and upper-income women. Regardless of income group, all pregnant women spent a substantial amount of extra money during pregnancy on food, clothing, medical examinations, transportation, ceremonies, servants, and delivery charges. These extra expenditures totalled Rs 1295.20 for low-income women, Rs 2913.68 for middle-income women, and Rs 4595.01 for high-income women. Given the fact that Indian women are investing substantial amounts in their pregnancies, increased attention must be given to prenatal care to prevent pregnancy wastage and the waste of scarce financial resources.     

Racial Disparities in Access to Care for Men in a Public Assistance Program for Prostate Cancer

California's IMPACT program provides all its enrollees with health insurance and social service resources. We hypothesized that racial/ethnic disparities in access to care might be attenuated among men served by this program. Our objective was to evaluate racial/ethnic differences in health services utilization and patient-reported health care outcomes among disadvantaged men in a prostate cancer public-assistance program, and to identify modifiable factors that might explain persistent disparities in this health care setting. We performed a retrospective cohort study of 357 low-income men enrolled in IMPACT from 2001 through 2005. We evaluated realized access to care with two health services utilization measures: (1) use of emergency department care without hospitalization and, (2) frequency of prostate-specific antigen testing. We also measured two patient-experience outcomes: (1) satisfaction with care received from IMPACT, and (2) confidence in IMPACT care providers. We observed significant bivariate associations between race/ethnicity and patient-experience outcomes (P < 0.05), but not utilization measures. In multivariable models, Hispanic men were more likely than white men to report complete satisfaction with health care received in IMPACT (adjusted OR = 5.15, 95% CI 1.17-22.6); however, the association between race/ethnicity and satisfaction was not statistically significant (P = 0.11). Language preference and self-efficacy in patient-physician interactions are potentially-modifiable predictors of patient-experience outcomes. We observed no racial/ethnic disparities in health services utilization among disadvantaged men served by a disease-specific public assistance program. The greater satisfaction and confidence among Hispanic men are explained by modifiable variables that suggest avenues for improvement.     

Meeting the child care needs of low-income families

Recent public policy changes have focused attention on the child care needs of families who are struggling to become or remain economically self-sufficient. This review essay describes public policies designed to assist low-income families, and it examines the ways in which the child care problems those families face differ from those of more advantaged families. Studies of child care choices show that low-income families value the same child-oriented characteristics of child care arrangements as do more advantaged families, but their choices are limited by pressing adult needs for care of acceptable quality that is affordable, available at odd hours, and offered at accessible locations. Steps that child care professionals can take to work with public agencies and low-income parents to address the child care needs of this vulnerable group are discussed.     

Child Healthcare in Two Farmworker Populations

Children in farmworker families are medically underserved. Little research has documented the healthcare of these children. This analysis uses data collected from two populations of Latino farmworker families, one located in western North Carolina and western Virginia, and the other located in eastern North Carolina, to describe and compare child healthcare utilization and mothers’ satisfaction with their children’s healthcare. Child, mother, household and health services characteristics are examined as causes of variation in child healthcare utilization and mothers’ satisfaction for each farmworker population. Results highlight strengths in the provision of healthcare to farmworker children, including most receiving care at a consistent healthcare facility, age appropriate time since last visit, and satisfaction with the care received. Shortcomings in farmworker child healthcare include few having a consistent healthcare provider, and many not receiving visits with recommended frequency. Differences observed in child health services between the two populations include dissatisfaction with care received, perceptions that healthcare staff members are disrespectful, and difficulties with transportation. Further research is needed to determine the best means of providing care to this underserved population.     

Who pays for health care in Asia?

We estimate the distributional incidence of health care financing in 13 Asian territories that account for 55% of the Asian population. In all territories, higher-income households contribute more to the financing of health care. The better-off contribute more as a proportion of ability to pay in most low- and lower-middle-income territories. Health care financing is slightly regressive in three high-income economies with universal social insurance. Direct taxation is the most progressive source of finance and is most so in poorer economies. In universal systems, social insurance is proportional to regressive. In high-income economies, the out-of-pocket (OOP) payments are proportional or regressive while in low-income economies the better-off spend relatively more OOP. But in most low-/middle-income countries, the better-off not only pay more, they also get more health care.     

Identifying children at risk of intellectual disability in UNICEF’s multiple indicator cluster surveys: Cross-sectional survey

BackgroundResearch on intellectual disability has been criticized for primarily addressing the situation of people in high-income countries.Objective/Hypothesis. To determine whether MICS6 data on ‘functional difficulty associated with learning’ (FDAL) in low- and middle-income countries could be used as a proxy indicator for intellectual disability.MethodsSecondary analysis of nationally representative data collected in Round 6 of UNICEF’s Multiple Indicator Cluster Surveys (MICS) on 244,915 children in 18 middle- and low-income countries.ResultsThe prevalence of FDAL in middle- and low-income countries was broadly similar to the estimated prevalence of intellectual disability in high-income countries. The association between risk of FDAL and household wealth was weak, with alternative measures of developmental delay showing significantly stronger associations with household wealth. The risk of making potential false negative errors in identifying FDAL increases as household wealth and level of maternal education decrease. The risk of making potential false positive errors in identifying FDAL is greater among more highly educated respondents, although this association is only statistically significant among older children.ConclusionsThe use of FDAL as a proxy indicator for intellectual disability cannot be recommended given: (1) it would probably underestimate the overall prevalence of intellectual disability in middle and low income countries; and (2) it is likely to be overestimate prevalence among families with higher socio-economic position (SEP) and underestimate prevalence among families with lower SEP.     

Assessing an intensive school-based assistance program to enroll uninsured children

Children eligible but not enrolled in subsidized health insurance programs, such as Medicaid and S-CHIP, received considerable outreach activity in recent years. Schools in low-income and middle-income communities often are cited as excellent places to find and reach parents. This study assessed the cost and effectiveness of contacting parents through schools, educating them about health insurance programs and preventive care, and assisting them with insurance applications. The accumulative cost per enrolled child was $75, and schools were able to locate and assist large numbers of uninsured children who had failed other outreach methods. School-based application assistance and parent education succeeded in improving child access to care and utilization of services.     

Children's mental health care: differences by race/ethnicity in urban/rural areas

This study examines racial/ethnic disparities in children's mental health and the receipt of mental health services, and whether those disparities differ between urban and rural areas. We find no significant difference between racial/ethnic groups in the prevalence of child mental health problems in either urban or rural areas. However, there are disparities in the use of mental health services. Hispanic children and Black children in urban areas receive less mental health care than their White counterparts, and the disparity persists for Hispanic children in rural areas, even after controlling for other relevant factors. Initiatives to improve access to mental health care for racial/ethnic minorities should recognize these disparities, and address the lack of culturally appropriate services in both urban and rural areas. In addition, outreach should raise awareness among parents, teachers, and other community members concerning the need for mental health services for minority children.     

Characteristics,Access, Utilization,Satisfaction, and Outcomes of Healthy Start Participants in Eight Sites

To describe the characteristics, access, utilization, satisfaction, and outcomes of Healthy Start participants in eight selected sites, a survey of Healthy Start participants with infants ages 6–12-months-old at time of interview was conducted between October 2006 and January 2007. The response rate was 66% (n = 646), ranging from 37% in one site to >70% in seven sites. Healthy Start participants’ outcomes were compared to two national benchmarks. Healthy Start participants reported that they were satisfied with the program (>90% on five measures). Level of unmet need was 6% or less for most services, except for dental appointments (11%), housing (13%), and child care (11%). Infants had significantly better access to medical care than did their mothers, with higher rates of insurance coverage, medical homes, and checkups, and fewer unmet needs for health care. Healthy Start participants’ rates of ever breastfeeding (72%) and putting infants to sleep on their backs (70%) were at or near the Healthy People 2010 objectives, and considerably higher than rates among low-income mothers in the ECLS. The high rate of health education (>90%) may have contributed to these outcomes. Elimination of smoking among Healthy Start participants (46%) fell short of the Healthy People 2010 objective (99%). The low-birth weight (LBW) rate among Black Healthy Start participants (14%) was three times higher than the rate for Whites and Hispanics (5% each). Overall, the LBW rate in the eight sites (7.5%) was similar to the rate for low-income mothers in the ECLS, but both rates were above the Healthy People 2010 objective (5%). Challenges remain in reducing disparities in maternal and child health outcomes. Further attention to risk factors associated with LBW (especially smoking) may help close the gaps. The life course theory suggests that improved outcomes may require longer-term investments. Healthy Start’s emerging focus on interconception care has the potential to address longer-term needs of participants.     

Do Medical Homes Reduce Disparities in Receipt of Preventive Services Between Children Living in Immigrant and Non-immigrant Families?

The patient-centered medical home model has the potential to reduce healthcare disparities among immigrant children. The purpose of this study is to examine the relationship between medical home (MH) participation and receipt of preventive services among immigrant children age 0-17. The study employed extant data from the National Survey of Children's Health, 2007 (NSCH). Logistic regression analyses were employed to assess the relationship between receipt of preventive services and MH status among immigrant and non-immigrant children. Due to primarily the lack of family-centered care, only 40% of immigrant children met the medical home criteria versus approximately 62% of non-immigrant children. Immigrant children have decreased odds of receiving preventive care despite MH status. Improving the family-centered care aspect of the MH is necessary to increasing medical home access to immigrant children and the receipt of preventive services for immigrant children who meet the MH criteria.     

Child Care: A Synthesis of Research

Four popular child care settings are family day care homes, care centers, relative care, and in-home care by non-relatives. Quality indicators in child care include curriculum that features child-centered developmental activities; responsive, sensitive, and affectionate caregivers; limited group size; low adult-child ratio; staff training and stability; parent involvement; and comprehensive social services such as health and nutrition. Children from low-income families who have received child care have shown short-term cognitive effects (e.g. immediate and positive intellectual gains and better preparation for entry into school); long-term cognitive effects (e.g. fewer grade retentions, reduced placement in special education classes, and greater high school completion and employment rates); and social-emotional effects (e.g. better self-esteem, higher ratings in social and emotional maturity, less antisocial behavior, and lower crime rate). Research indicates that child care may enhance social and intellectual development for middle class children as well as disadvantaged children.     

Explaining the gender gap in health services use among Ghanaian community-dwelling older cohorts

Although gender differences in use of health services have been documented, little is known about whether such disparities vary by marital and socioeconomic status in later life, especially in low- and middle-income countries. We examined the relation of gender to use of health care among community-dwelling older Ghanaians (N = 1200) and whether marital status and income moderated this relationship using data from the Aging, Health, Psychological Wellbeing and Health-seeking Behavior Study conducted in 2016/2017. Multivariate logistic regression modeling showed no significant gender disparities in use of health care, adjusting for covariates. However, married women were less likely to use health care than married men (adjusted Odds Ratio [aOR] = 0.324, 95% confidence interval [CI]: 0.146–0.718). Further, while married older people with higher incomes had lower odds of using health care (aOR = 0.355, 95% CI: 0.137–0.924), use of health services was greater in married women with higher incomes compared with their male counterparts (aOR = 8.695 (95% CI: 1.233–61.296). The modifying effects of marital status and income appeared substantial in explaining gender differences in use of health services in later life. These findings have implications for health policy, health promotion and quality of life of older people.     

Continuity of care and delivery of ambulatory services to children in Community Health Clinics

This study assesses how continuity of care influences receipt of preventive care and overall levels of ambulatory care among children and adolescents in community health clinics (CHCs). It is a secondary data analysis of the 1988 Child Health Supplement to the National Health Interview Survey. Of 17, 110 children in the sample population, the 1465 who identified CHCs as their routine source of care formed the study population. Continuity of site was defined as identification of a CHC as a source of both routine and sick care, and continuity with a clinician was defined as identification of a specific clinician for sick visits. In bivariate analyses both continuity with the CHC and with a specific clinician were associated with increased levels of preventive care and overall ambulatory care. In logistic regression models, continuity of care was associated with nearly a two-fold increase in the odds of receiving age-appropriate preventive care. Alternatively, insurance status was a better predictor of receipt of overall levels of ambulatory care. We conclude that expanding financial access alone is unlikely to sufficiendy improve low-income children's access to Community Health Clinics. Additional emphasis on localizing the delivery of both routine and sick care services in a single site or with a specific clinician may be needed to achieve higher levels of both preventive care and overall ambulatory care.This research project was supported by the following grants: NRSAS-PHS 1 732 PE 10009-02; AHCPR F32 HS00070 and AHCPR T32 HS 00029.